Living on the streets, in extremely precarious conditions in terms of safety, sleep and food, usually leads, for practical or psychological reasons, to a deterioration in personal hygiene and clothing. This deteriorated state will be a warning signal for carers, and the extent of the deterioration will most often indicate the seriousness of the situation.
A contact with the person will reveal the reason for this state of affairs: sometimes obvious practical aspects (lack of money or information for people who have just arrived in Belgium, for example) are the only causes of the problem, which is therefore easy to resolve. More often, in a chronically fragile population, this condition reflects a deep-seated malaise, a complex and chronic situation that cannot be resolved or even understood so quickly. The patient will be unable to put forward a valid reason for their lack of hygiene, and we will even see them partially or even totally in denial of their situation.
An implicit message
This degraded hygiene constitutes the patient's implicit and unconscious message. In the first case, it simply expresses his inability to ask for help, either because he doesn't know, or because he doesn't dare, and therefore something quite trivial. In the second situation, it will be something quite different, and the first evidence of this will be partial or total denial: I don't need help, other people need you more, No, no, I'm perfectly fine, don't worry about me.
The person has psychically ‘withdrawn’ from their body, faced with a situation - life on the streets - whose brutality is unbearable to them. From now on, they live as insensitive observers of their own lives, with no feelings or pain, no demands and no plans, erased from the world, rejecting others by their smell or appearance.
This is where the body really speaks for the patient. And it's up to the carer to understand the message and dare to grasp it. Send the patient a gentle but clear message: ‘When I see you in this state, I tell myself that you are not well, even if you tell me otherwise.'
By doing this - and more often than not it has to be done several times - the carer does the person a great service: they give them the chance to get back in touch with their body, and with their life. Paradoxically perhaps, this also shows the importance the carer attaches to the patient, to respecting their person, even if they may no longer be capable of doing so. By communicating their concern, their worry, the carer is conveying esteem and respect, a genuine consideration for the person. Before self-esteem, at least the esteem of others.
Given the possibilities this offers for progress, for recovery, it is very important, even if it's not so easy to overcome our reticence about this subject, to give ourselves the means (this can be learned and trained) to be able to discuss this with the person. Every carer should be able to seize the opportunities that arise to open this door, despite the reluctance that everyone may have to broach this often taboo subject.
The relationship between bodily hygiene and situational diagnosis will be found throughout support, not just on the streets, but also in housing. Improvements or deterioration can quickly reflect changes in well-being, self-esteem and mood. Looking for the causes of the improvement, working them out and highlighting them with the person concerned, helps to anchor the mechanisms of resilience and well-being a little more firmly. Detecting deterioration can make it possible to deal more quickly with a worry, stress, a drop in mood, and avoid it getting worse.
Hygiene is therefore a fairly sensitive and very useful monitoring tool. But this requires being able to observe and measure hygiene and behaviour as objectively as possible so as to be able to assess their evolution over time. In team contexts, this also means that findings can be shared, like a clinical examination after all, rather than impressions or feelings. We're all familiar with the ‘he's a cata!’ dropped at a team meeting, which may be relieving, but is of little use in guiding action or conveying an objective finding.
For a relatively standardised measure of hygiene (and behaviour), the Street Nurses teams use the CVC score (for Body-Clothing-Behaviour)2, a score for evaluating the degree of integration which allows each of these aspects to be rated from 0 to 3, for a total of 9. A score of less than 6 requires further investigation in order to establish a diagnosis of the situation. This score was designed to be taken on the street, at a certain distance and without communicating with the person, but it can obviously be used in more favourable conditions, in accommodation or in consultation.
"Street Nurses is an association that aims to reintegrate severely socially deprived rough sleepers through hygiene, healthcare, work on resources and overall long-term support. Our vision is that, for everyone, sustainable reintegration into a housing solution, whatever that may be, is not only desirable but possible, and that the housing solution is less an objective in itself than a tool for reintegration into society, better health and personal fulfilment.
In this long-term work, which is often fraught with pitfalls, a good understanding of this population's relationship with the body, and how to use it, can be a valuable aid to the carer. Often, unfortunately, due to a lack of information or experience, some carers or carers are reluctant to go down this road with their patients, unknowingly losing information, time, or opportunities to help them progress."
A starting point for progress dynamics
Working on hygiene will prove to be a formidable tool for moving forward with patients. Firstly, because the well-being associated with hygiene care (a scent, freshness on one or more parts of the body) and the activation of circulation will help the patient to reconnect with (positive) emotions linked to the body and thus reconnect with his or her body, and enable him or her to reappropriate it, to re-inhabit it. This is done step by step, and sometimes the emotion can be more visible and prominent: tears at the first shower in a very long time, for example.
These are emotional moments when the person reconnects with their body, with that part of them that they have detached themselves from, at least partially, to better withstand the difficulties of life on the streets. But it can also be an emotion, as the person reconnects more directly and consciously with the difficulties of their current situation, and possibly with what they have lost. This reconnection and work is done in small steps; first a wipe on the hands, then the face, then washing the hands and face, then the feet, then taking a shower.
And this dynamic has another advantage: it allows the person to realise that they can set themselves goals (‘next week we'll cut our nails and wash our hands’) and achieve them (with varying degrees of help from the care team). Gradually, the person will get back into a dynamic of progress and more general objectives: redoing their identity card, getting a flat, reducing their consumption, etc. They will regain confidence in themselves and in life. After regaining control of their bodies, patients move on to regaining control of their lives.
.
At this point, the body, which had been completely neglected as a simple, untended working tool, becomes the tool for survival and longer-term life, which are now possible and envisaged. This is the moment when opportunities open up to make progress on medical aspects that have been neglected for years: diabetes that has never been perfected, a hip that hurts, a neglected hernia... The body was a burden and a source of suffering, in a context where long-term survival was uncertain, it now becomes an ally that needs to be cared for.
An element of socialisation and self-affirmation
This transition to better hygiene and self-care obviously requires the patient to be touched, guided, seen and recognised by the carer. It's the carer's turn to have an implicit language, the opposite of the one the patient had had: through touch, through gentle and beneficial gestures, through their objective but always benevolent gaze, the carer recognises, delineates and revalues this body, and takes it out of the one-upmanship of degradation that was becoming the only means of communication.
A different discourse, a different logic can be put in place: it is no longer necessary to be repulsive and in danger to attract attention, or to repel and thus guarantee safety. On the contrary, it is through a pleasant and healthy appearance that a person enters into a relationship with the world, and it is through a home that a person can ensure their safety. By overcoming the disgusting barrier that was at the same time a cry for help, by entering directly and positively into contact with this body, the carer re-establishes that care of the body that enables relationships with others and integration, first in the person's place, then by encouraging him or her to regain autonomy over this aspect of his or her life. This stage sounds simple when you put it like that, but of course it can take weeks or months. It's a process that moves forward like a tide: one advance is followed by a retreat, but one that doesn't go as far as before, and so gradually we move towards autonomy.
Of course, in this bumpy and chaotic journey, many other things will come into play and need to be worked on as well: social advances, the eventual return to housing, dialogue with the various people involved, psychological follow-up, etc. But it would be a big mistake to underestimate the importance of these things. But it would be a big mistake to underestimate the importance of touch, of warm closeness, of a kind and encouraging look, of a smile that will stimulate progress, at the same time as the necessary distance that gives security to both patient and carer. These are important tools that everyone should be able to use, but with which you need to be sufficiently familiar to avoid making any mistakes.
The gradual autonomy in hygiene care and the positive appearance that will result from it will greatly contribute to an improvement in self-esteem, which opens up the whole field of meeting others, making decisions, and opportunities for socialisation, the keys to reintegration into society. The body, now a source of positive attention from others, enables people to assert themselves and gradually (re)take their place in society. Other goals and ambitions are now possible.
Reconnecting with the body
The deterioration in hygiene and self-care is an important constant in very precarious living conditions. Often reduced to its most superficial aspects, it nonetheless constitutes a crucial implicit message that carers have every interest in grasping if they want their help to be transformative rather than palliative.
Through a decisive and proactive, yet respectful and benevolent approach, he has the opportunity to lead his patient in small steps towards a reconnection with the body and emotions that life on the street had most of the time destroyed.
This requires an open mind, non-judgement, a certain amount of training, patience and perseverance. Proximity, including physical proximity, plays a major role in this process. It should be part of familiar practices. Regular, objective assessment means that monitoring can be adjusted sensitively and rationally. Insofar as the carer is prepared to move forward with the patient on this long and difficult journey, it becomes the scene of an encounter whose depth is most of the time unexpected, and many successes rightly or wrongly unhoped for.
Pierre Ryckmans, co-coordinator and medical manager Street Nurses
Hygiene is essential for social reintegration
Find out more about the role of hygiene in our street methodology
More information